Hindawi Publishing Corporation BioMed Research International Volume 2015, Article ID 817298, 11 pages http://dx.doi.org/10.1155/2015/817298
Research Article Quitline Use and Outcomes among Callers with and without Mental Health Conditions: A 7-Month Follow-Up Evaluation in Three States Katrina A. Vickerman,1 Gillian L. Schauer,2 Ann M. Malarcher,3 Lei Zhang,3 Paul Mowery,4 and Chelsea M. Nash1 1
Alere Wellbeing, Inc., 999 Third Avenue, Suite 2000, Seattle, WA 98104, USA Carter Consulting, Inc., Contractor to Office on Smoking and Health, Centers for Disease Control and Prevention, 4770 Buford Highway NE, MS F-79, Atlanta, GA 30341, USA 3 Office on Smoking and Health, Centers for Disease Control and Prevention, 4770 Buford Highway, NE MS F-79, Atlanta, GA 30341, USA 4 Biostatistics, Inc., 1738 Illehaw Drive, Sarasota, FL 34239, USA 2
Correspondence should be addressed to Katrina A. Vickerman;
[email protected] Received 26 December 2014; Revised 6 May 2015; Accepted 6 May 2015 Academic Editor: Kamran Siddiqi Copyright © 2015 Katrina A. Vickerman et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. To examine abstinence outcomes among tobacco users with and without a reported mental health condition (MHC) who enrolled in state tobacco quitline programs. Methods. Data were analyzed from a 7-month follow-up survey (response rate: 41% [3,132/7,459]) of three state-funded telephone quitline programs in the United States that assessed seven self-reported MHCs at quitline registration. We examined 30-day point prevalence tobacco quit rates for callers with any MHC versus none. Data were weighted to adjust for response bias and oversampling. Multivariable logistic regression was used to examine cessation outcomes. Results. Overall, 45.8% of respondents reported ≥1 MHC; 57.4% of those reporting a MHC reported ≥2 MHCs. The unadjusted quit rate for callers with any MHC was lower than for callers with no MHC (22.0% versus 31.0%, 𝑃 < 0.001). After adjusting for demographics, nicotine dependence, and program engagement, callers reporting ≥1 MHC were less likely to be abstinent at followup (adjusted OR = 0.63, 95% CI = 0.51–0.78, 𝑃 < 0.001). Conclusions. More intensive or tailored quitline programs may need to be developed among callers with MHCs as their quit rates appear to be lower than callers without MHCs.
1. Introduction Individuals with mental health conditions (MHCs) are twice as likely to smoke compared to the general population [1] with smoking prevalence varying from 34% to over 60% depending on specific diagnosis [2, 3]. Individuals with MHCs are also more likely to die prematurely—up to 25 years earlier on average in some populations [4]—and, similar to the general population, tobacco-related conditions such as heart disease and cancer are the leading causes of death among individuals with MHCs [4]. Smoking rates have significantly declined over the past decade among the general population [5], but rates have
not declined among individuals with MHCs [6]. Although studies have shown that evidence-based treatment increases cessation among persons with MHCs [7–10], individuals with MHCs may have unique treatment needs [2, 11] and, based on epidemiological evidence, have a lower rate of successful cessation than those without MHCs [1, 12]. There is growing evidence that, on average, quitting tobacco does not negatively impact long-term psychological functioning for persons with MHCs—a concern often raised by providers [13]. In fact, treatment may reduce MHC symptoms and improve functioning [14–17]. State tobacco quitlines in the United States provide evidence-based tobacco cessation treatment to more than
2 400,000 smokers annually, including free phone-based cessation counseling and often access to nicotine replacement therapy (NRT) [18, 19]. Approximately one-fourth of quitline callers meet criteria for major Depression [20] and approximately half or greater may have a MHC [21, 22]. Compared to those who try to quit with no support, quitline counseling increases the odds of quitting by 60% in the general population [11] and is a cost-effective public health intervention [23–27]. Quitlines may be a particularly valuable resource for individuals with MHCs because they reduce barriers to care (i.e., cost and transportation) [28]. Little is known about the effectiveness of quitline counseling for individuals with MHCs. Lower quit rates for callers with a MHC have been reported in several conference presentations [21, 22, 29], whereas other researchers found no differences in quit rates for MHC and non-MHC populations [30] or for callers with and without a positive Depression screen [27]. In the two published studies examining MHCs among quitline callers, callers to the California Smokers’ Helpline with major Depression were less likely to quit at two-month follow-up (19% versus 28%) [20], and callers to the New York State Smokers’ Quitline who were heavy drinkers had lower abstinence rates at two-week follow-up compared to moderate drinkers [31]. Quit rates among quitline callers with other MHCs, such as Attention Deficit Hyperactivity Disorder, Bipolar Disorder, Generalized Anxiety Disorder, Posttraumatic Stress Disorder, and Schizophrenia, have not been published. Accordingly, the current study examines characteristics and quit outcomes for callers to three state quitlines who reported on seven MHCs at program registration. We hypothesized that callers with MHCs would also have other characteristics that may make it more challenging for them to quit, such as higher tobacco dependence and lower socioeconomic status [1, 11, 32] and that callers with MHCs would have lower 30-day point prevalence quit rates at 7month follow-up after adjusting for these factors.
2. Methods 2.1. Sample Selection. This observational study includes data from four evaluation samples of quitline registrants from January 2012 through May 2013: one in Maryland, one in Nebraska, and two in North Carolina (one with January– June 2012 registrants and the other with August 2012– May 2013 registrants). These evaluations were conducted as part of each state’s ongoing program outcome evaluation procedures. The states agreed to contribute their evaluation data and participate in this secondary data analysis. These state quitlines were selected because they asked a custom registration question to assess self-reported MHC status, offered a multiple-call phone-based cessation program, and had quitline services delivered and evaluations conducted by the same quitline vendor (Alere Wellbeing). After enrolling in the quitline program and completing their first coaching call, callers were selected for evaluation follow-up based on the following criteria. All tobacco users who had enrolled in the phone-based state quitline program in Maryland and
BioMed Research International Nebraska were selected for evaluation (census sample), until the final three months of the Maryland evaluation, when random sampling was used due to increased quitline call volumes, and thus an influx of individuals eligible for the evaluation. Callers who were pregnant, Medicaid-insured, or reported having a MHC were oversampled using a probability sampling scheme in the North Carolina evaluations. Additional details regarding sampling methods are presented in Table 1. For all evaluations, quitline participants were eligible for inclusion if they were English or Spanish speaking, 18 years or older, and a tobacco user at enrollment, provided a valid phone number, consented to evaluation follow-up during registration, and had completed at least one coaching call. Data weighting procedures were used to accommodate population oversampling during analysis. 2.2. The Quitline Program. All three states offered a multiplecall phone-based cessation program for the duration of the study time frame, which included an initial assessment and planning call plus three to four additional coaching calls, a printed quit guide, and access to the Web Coach website, an interactive web-based cessation resource designed to complement the phone program. The quitline program is based on social cognitive theory and the United States Public Health Service Clinical Practice Guidelines [11, 33]. Calls focus on creating a quit plan, using problem solving and skills development to address cravings and triggers, leveraging social support, and using cessation medications to achieve abstinence and avoid relapse. All tobacco users who were ready to quit in the next 30 days at the time of registration were eligible for the multiple-call program. A one-call program was available for callers not ready to quit or not interested in the multiple-call program. Only a small number of callers selected the one-call program, and only 98 completed a follow-up survey (2.9% of all completed surveys) during the study time frame. Accordingly, we have excluded those opting for the one-call program from these analyses. Free NRT was provided through the quitline to eligible callers in Maryland and North Carolina. Table 1 presents additional details regarding quitline services and NRT offerings during the study time frame. 2.3. Follow-Up Survey Administration. Evaluations were conducted in accordance with recommendations from the North American Quitline Consortium for assessing quit outcomes for state quitlines in North America [34]. Sampled participants were contacted approximately 7 months after completing their first coaching call. Participants with a valid email address who consented to being contacted via email were emailed an invitation to complete the follow-up survey online. Those who did not complete the survey after three reminder emails were then contacted by trained interviewers to complete a phone-based survey. Interviewers made at least one attempt per day to reach each participant by phone; attempts were made on up to 11 different days over approximately a 4-week period. Across the three states, 7,646 tobacco users who enrolled in the multiple-call programs within January 2012–May 2013
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Table 1: Quitline services for tobacco users enrolled in the Nebraska, North Carolina, or Maryland state tobacco quitlines. Services Registration dates included
State quitline Nebraska 1 August 2012–31 October 2012
North Carolina Evaluation 1: 1 January 2012–30 June 2012 Evaluation 2: 8 August 2012–31 May 2013 Evaluation 1: 827/1,966 Evaluation 2: 753/1,875 Evaluation 1: oversampled Medicaid Evaluation 2: oversampled Medicaid, pregnant, MHCs
Maryland 1 December 2012–31 May 2013
All tobacco users Four-call program for tobacco users ready to quit in the next 30 days
7 M responders/number in sample
136/342
Evaluation sample selection
Census
One-call programa Multiple-call program (Assessment and planning call plus 3-4 outbound calls)
All tobacco users Five-call program for tobacco users ready to quit in the next 30 days
All tobacco users
Ten-call program Web Coach (Interactive online complement to phone coaching)
Pregnant tobacco users
Pregnant tobacco users
Pregnant tobacco users
All phone program participants
All phone program participants
All phone program participants
Not offered
For tobacco users who preferred to receive only online support (starting 1 January 2012)
For tobacco users who preferred to receive only online support (starting 12 January 2012)
(i) Not offered (ii) Proof of quitline enrollment and completion of a program call was a component for some Medicaid participants to receive NRT or medications through their pharmacy benefits manager
(i) Eight-week supply of patch, lozenge, or gum to multiple-call enrollees in the following groups: (a) all (1 January 2012–20 May 2012) (b) uninsured (starting 19 December 2012) (c) Orange County residents (starting 13 February 2013) (ii) Two-week (starting 13 February 2013) supply of patch, lozenge, or gum for multiple-call enrollees who were insured (expanded to 8-week supply on 22 May 2013) (iii) Eight-week supply of patches for multiple-call enrollees with state employees’ health insurance (duration of study timeframe)
Four-week supply of patch, lozenge, or gum to all multiple-call (once every 12 months)
Stand-alone web-based tobacco cessation Programa
Direct Mail Order (DMO) nicotine replacement therapy (NRT)
Four-call program for tobacco users ready to quit in the next 30 days
1,546/3,463 Census; random sampling (March–May 2013)
Note: 7 M = 7-month survey; MHCs = mental health conditions (conditions assessed: Attention Deficit Hyperactivity Disorder, Bipolar Disorder, Depression, Drug or Alcohol Use Disorder (or Substance Use Disorder), Generalized Anxiety Disorder, Posttraumatic Stress Disorder, and Schizophrenia). a This study focused on callers who enrolled in a multiple-call telephone program. Individuals who selected the one-call program or the stand-alone web-based tobacco cessation program were not included. Limited 7-month evaluation data was available for these groups because a small minority selected these services and only Maryland collected follow-up data for the stand-alone web-based program during this timeframe.
were selected for evaluation; 3,262 completed the 7-month survey (response rate: 42.7%). The final sample includes 3,132 participants (40.9%) who responded to the question assessing MHC status during quitline registration and also provided their quit status at 7-month follow-up. 2.4. Measures 2.4.1. Baseline Program Registration Data. To assess MHC status at program registration, callers were asked a behavioral health question similar to one developed by a NAQC advisory forum [35]: “Do you currently have any mental health conditions, such as Attention Deficit Hyperactivity
Disorder (ADHD), Bipolar Disorder, Depression, Drug or Alcohol Use Disorder (or Substance Use Disorder; SUD), Generalized Anxiety Disorder (GAD), Posttraumatic Stress Disorder (PTSD), and Schizophrenia?” Registration agents paused briefly after each condition to allow participants to respond. We examined outcomes for callers who reported any MHC versus no MHCs. In addition, because the majority of callers with a MHC reported comorbid MHCs, we also established four mutually exclusive diagnostic groups. The groups were based on conditions that typically have the greatest impact on daily functioning and conditions that were highly comorbid in our sample, such as Depression and anxiety disorders: (Group 1) Schizophrenia or Bipolar
4 Disorder; (Group 2) Depression, GAD, or PTSD but no report of Schizophrenia or Bipolar Disorder; (Group 3) SUD or ADHD but no report of the other conditions; and (Group 4) no MHC. Demographics (age, gender, education, race/ethnicity, and chronic health condition status [presence of asthma, diabetes, chronic obstructive pulmonary disease, and/or coronary artery disease]), baseline tobacco use data (type [cigarette, cigar, pipe, smokeless, and other], amount [cigarettes per day or CPD], time to first use after waking [TTFU]), and health insurance status (private, Medicare, Medicaid, and uninsured) were collected during quitline registration, per NAQC guidelines [36]. CPD and TTFU were used to create a nicotine dependence index. CPD was recorded on a continuous scale and categorized into four groups: (1) 0–10, (2) 11–20, (3) 21–30, and (4) 31 or more. TTFU was recorded on a 4-point scale: (1) 61 or more minutes, (2) 31–60 minutes, (3) 6–30 minutes, and (4) within 5 minutes. The index is the mean of these two 4-point scales. 2.4.2. Program Engagement. The number of coaching calls completed in the program and whether NRT was sent from the quitline were recorded and examined as indicators of program engagement. 2.4.3. 7-Month Follow-Up Survey. Tobacco cessation outcomes were assessed during the 7-month follow-up survey by asking respondents, “When did you last use tobacco, even a puff or a pinch? (Please do not include electronic cigarettes)”. Respondents’ self-reported last tobacco use data were used to calculate 7- and 30-day point prevalence tobacco quit rates. Participants were also asked whether they had used any cessation medications to help them quit since enrolling in the quitline (NRT patch, gum, lozenge, inhaler, nasal spray, Chantix/varenicline, Zyban/bupropion/Wellbutrin, and “other” medication). 2.5. Analyses. Data were weighted separately to the populations eligible for the evaluation for each state for nonresponse to the 7-month survey based on age, gender, race/ethnicity, insurance status, call completion, and dependence level. Data from the three states were then combined and poststratification weights were computed to adjust for oversampling in North Carolina evaluations (by pregnancy status, presence of a MHC, and Medicaid status); all variables used during response bias weighting were also included in this step. Weights were computed using a raking macro [37]. Weighted analyses were conducted in SAS 9.3 (SAS Institute Inc., Cary, NC). The purpose of these weighting procedures was to increase the generalizability of the 7-month survey results to the entire population eligible for evaluation in these states (𝑁 = 28,391) by adjusting the weights of individuals’ 7month survey data to ensure that respondent characteristics were similar to population characteristics on the weighting variables listed above. Demographics, tobacco use characteristics, program engagement, and 7-month survey outcomes were examined for callers with and without reported MHCs. Multivariable logistic regression was used to assess whether callers with
BioMed Research International any MHCs were less likely to quit for 30 days or more at follow-up compared to those without MHCs, controlling for age, gender, race/ethnicity, education, insurance status, number of calls completed, use of cessation medications reported at follow-up, and state (to account for state-level differences in tobacco control environment and quitline services). Two models were estimated; the first examined any versus no MHCs, and the second examined MHC status divided into the four mutually exclusive condition groups described above (Group 1: Schizophrenia/Bipolar Disorder; Group 2: Depression/GAD/PTSD; Group 3: SUD/ADHD; Group 4: no MHC). In the second model, each condition group was compared to no MHC and to each other.
3. Results Nearly half (45.8%) of survey respondents reported one or more MHCs at baseline including: 31.9% Depression, 21.2% GAD, 13.6% Bipolar Disorder, 8.4% PTSD, 7.4% ADHD, 6.7% SUD, and 3.6% Schizophrenia. The majority (57.4%) of those reporting a MHC reported two or more comorbid MHCs (26.3% of the total sample). Compared to those without MHCs, a higher percentage of respondents with a MHC were younger, female, White nonHispanic, and Medicaid-insured, had less than a high school degree, had higher tobacco dependence (based on CPD and TTFU), had a chronic health condition, and completed three or more program calls (Tables 2 and 3). A lower percentage of callers with a MHC had been mailed NRT through the quitline; however, there were no differences in self-reported use of NRT since program registration (Table 3). There were no differences in type of tobacco used (Table 2) or satisfaction with the quitline (Table 3). 3.1. Quit Rates for Callers with and without MHCs. At the time of the 7-month survey, the unadjusted quit rate for callers with a MHC was significantly lower than for callers without a MHC (30-day point prevalence quit rates: 22.0% (95% CI = 19.5%–24.5%) versus 31.0% (95% CI = 28.4%– 33.6%), 𝑃 < 0.001) (Table 3). Multivariable logistic regression analyses confirmed that callers who reported one or more MHCs were significantly less likely to quit at follow-up (adjusted OR = 0.63, 95% CI = 0.51–0.77, 𝑃 < 0.001) (Table 4). Callers with higher baseline tobacco dependence and Medicaid insurance (compared to private) were also less likely to quit at follow-up, and callers who completed more program calls were more likely to quit. 3.2. Quit Rates by MHC Group. Unadjusted 30-day point prevalence quit rates for the mutually exclusive MHC groups were as follows: Schizophrenia or Bipolar Disorder (Group 1) [19.4% (95% CI = 15.4%–23.3%)]; Depression, GAD, or PTSD without Schizophrenia or Bipolar Disorder (Group 2) [24.0% (95% CI = 20.6%–27.5%)]; SUD or ADHD without the other five conditions (Group 3) [18.3% (95% CI = 9.5%–27.1%)] (data not shown in tables). In multivariable logistic regression analyses, all three condition groups were significantly less likely to quit compared to callers with no MHC (Table 4);
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Table 2: Baseline characteristics among multiple-call program callers with and without self-reported MHCs in three states.
Baseline data Age – mean (SD) Gender Male Female Education Less than high school GED High school degree Some college/trade school College/trade school degree Race/ethnicity White, non-Hispanic Black, non-Hispanic Hispanic Other, non-Hispanic Insurance status Medicaid Uninsured Private Medicare Tobacco typeb Cigarette Cigar Pipe Smokeless Other CPD – mean (SD) 0–10 11–20 21–30 31+ Time to first use
